Experimental Gerontology 48 (2013) 85–93

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Experimental Gerontology
journal homepage: www.elsevier.com/locate/expgero

Efficacy of physical exercise intervention on mobility and physical functioning in

older people with dementia: A systematic review
Kaisu Pitkälä a,⁎, Niina Savikko a, Minna Poysti a, b, Timo Strandberg c, Marja-Liisa Laakkonen a, d
a
Helsinki University Central Hospital, Unit of General Practice and Primary Health Care and University of Helsinki, Department of General Practice and Primary Health Care, Finland
b
The Social Insurance Institution of Finland, Rehabilitation Unit, Finland
c
University of Oulu, Institute of Health Sciences/Geriatrics and Health Centre Oulu, Oulu, Finland
d
City of Helsinki Health Centre, Rehabilitation Unit, Finland

a r t i c l e i n f o a b s t r a c t

Article history: Numerous trials have shown that physical activity and exercise training have beneficial effects in general
Received 13 February 2012 older populations. However, few have studied its effectiveness among people with dementia. The aim of
Received in revised form 5 August 2012 this systematic review is to examine the efficacy of trials using a rigorous randomised, controlled design
Accepted 27 August 2012
and including physical activity or exercise as a major component of intervention on the physical functioning,
Available online 31 August 2012
mobility and functional limitations of people with dementia. We found 20 randomised controlled trials that
Section Editor: A. Simm included a total of 1378 participants. Of these, only three were of high methodological quality, and six of
moderate quality. Nevertheless, these studies consistently show that intensive physical rehabilitation
Keywords: enhances mobility and, when administered over a long period, may also improve the physical functioning
Dementia of patients with dementia.
Exercise © 2012 Elsevier Inc. All rights reserved.
Physical functioning
Mobility
Fuctional limitation
Systematic review

1. Introduction
The prevalence of dementia increases with age. Among people
85 years or older, 20–30% may have Alzheimer's disease (Lobo et al.,
2000). Over 80% of nursing home residents in Finland have dementia
(Noro, 2005), which is the most common reason for nursing care at
home and family caregiving of older people. Dementia is one of the
most expensive diseases (Gustavsson et al., 2011), the need for help
in daily activities and various kinds of social services account for
over 85% of public costs account (Jedenius, 2010). Dementia is, there-
fore, one of the most important challenges in the development of re-
habilitation among the aged.
In addition to cognitive decline, neuropsychiatric symptoms and
functional disabilities are common features of dementia (Fernández et
al., 2010; Knoptman et al., 2002). Functional deficits may appear even
in the early phases of progressive memory diseases (Knoptman et al.,
2002) and, during their course functional deficits lead to disabilities,
the need for help and, finally, to permanent institutional care (Cotter,
2007). Rigidity increases and walking speed decreases as the disease
progresses. Rigidity and functional limitations may further impair
⁎ Corresponding author at: University of Helsinki – Department of General Practice
and Primary Health Care, P.O. Box 20, 00014 University of Helsinki, Finland. Tel.: +358
9 191 27405.
E-mail address: kaisu.pitkala@helsinki.fi (K. Pitkälä).
one's ability to manage even the simplest activities of daily living
(ADLs) and may also make homecare more difficult for the caregiver.
Dressing, undressing and transfers become slow limiting person's abil-
ity to perform outdoor activities. This process is enhanced by weight
loss, sarcopenia and progressive frailty, which are typical of dementia
and which impair body control (Gillette-Guyonnet et al., 2007). Even
in the early stages of dementia, patients may already have problems
in walking and maintaining postural balance control. Dementia is a sig-
nificant risk factor for falls (Allan et al., 2009; Tinetti, 2003).
Physical exercise has proved beneficial to older peoples’ mobility
and even physical functioning (Liu and Latham, 2009; Rydvik et al.,
2004), in preventing falls (AGS, 2011) and, possibly, cognition
(Lautenschlager et al., 2008) and mood (Blake et al., 2009). A total
of 121 randomised, controlled trials have examined the effectiveness
of strength training in general populations of older people (Liu and
Latham, 2009). A quarter of these studies have shown effectiveness
in physical functioning and in functional limitations such as walking
speed. Exercise rehabilitation has also shown to be effective among
frail older people living in institutions (Forster et al., 2009). Exercise
decreases functional limitations and is safe (AGS, 2011; Liu and
Latham, 2009).
Among people with dementia, the effectiveness of rehabilitation
has received less attention; for example, evidence of the effectiveness
of exercise in preventing falls in these patients is lacking (AGS, 2011).
Some prior systematic reviews have examined the effectiveness of

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http://dx.doi.org/10.1016/j.exger.2012.08.008
86 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93
exercise in frail older people, but some of those focusing on people
with dementia are fairly old or include surprisingly few clinical trials
(Forbes et al., 2008; Hauer et al., 2006; Littbrand et al., 2011). Some of
these studies focus on frail older people in long-term care settings
and, although consisting of a proportion of people with dementia,
also include cognitively intact people (Forster et al., 2009). Further-
more, some examine the effects of exercise on motor performance
or cognitive functioning (Hauer et al., 2006; Littbrand et al., 2011). Fi-
nally, some also include studies which are not rigorously randomised
(Blankevoort et al., 2010; Heyn et al., 2004, 2008). People with de-
mentia have specific problems and risks related to their physical func-
tioning. In light of the magnitude of problems related to mobility,
functional limitations, disability and risk for falls in patients with de-
mentia, surprisingly few studies have investigated the effectiveness of
physical exercise or rehabilitation in them. In our service system the
attitude towards the rehabilitation of older people with dementia
has been quite reserved. Thus, this systematic review of randomised,
controlled studies aimed to investigate whether rigorous trials have
shown the efficacy of exercise training in the mobility, functional lim-
itations and physical functioning of people with dementia.
2. Methods
We searched PubMed, Cochrane, DARE, Cinahl and Nursing@Ovid
databases with the words “dementia” OR “Alzheimer” OR “cognitive de-
cline” combined with the words “exercise” OR ”exercise training” OR
“physical exercise” OR ”physical activity” using the filter randomised,
controlled trial or clinical trial. Only publications in English language
were included. We performed the search in September 2011 and in-
cluded all articles that fulfilled our criteria and were published through
31 August, 2011. Fig. 1 describes the database search. We also reviewed
all reference lists of the articles to find relevant publications. We also ex-
amined all previous, relevant systematic reviews on this topic
(Blankevoort et al., 2010; Forbes et al., 2008; Forster et al., 2009;
Hauer et al., 2006; Heyn et al., 2004, 2008; Littbrand et al., 2011;
Electronic literature search.
Databases: Medline, Cinahl,
Nursing@Ovid, Cochrane, DARE
Citations from database search: N=575
Fully accessed after removing
duplicates and scanning abstracts
N=117
Papers excluded after evaluation
of full text N=100
Reasons for exclusionn: Reviews , not
randomised controlled trials, all
participants did not have dementia,
effects of physical functioning or
mobility were not evaluated
Articles included from
database searches N=17
Articles included from
reference lists N=2
Articles included from authors
knowledge of area N=1
Fig. 1. Results of search strategy.
Potter et al., 2011). Our objective was to find as comprehensively as
possible all randomised, controlled trials in older people with dementia
investigating efficacy of physical exercise on physical functioning, mo-
bility or related functional limitations as outcome measures. Physical
functioning is defined as the ability to perform activities needed in
daily life, either basic activities of daily living (BADL) or instrumental ac-
tivities of daily living (IADL) (Jette, 2006). Therefore, disability refers to
the inability to perform in one or more dimensions of physical function-
ing. Functional limitations are defined as difficulties an individual may
have in executing activities; for example, functional limitations in mo-
bility (mobility limitation) refer to a gait speed that may be slow or to
an individual who may have difficulty getting up stairs (Fuller-
Thomson et al., 2009; Jette, 2006). Functional limitations often precede
disability in disablement process (Verbrugge and Jette, 1994) and, thus,
physical functioning can be seen as a stronger outcome measure than
functional limitation or mobility limitation.
We excluded other disease populations besides those with de-
mentia. No exclusion criteria were set for length of intervention or
follow-up. In the studies reviewed physical exercise had to be the
main intervention either alone or in combination with other inter-
ventions. This decision to include multi-component interventions
was made because there are very few pure exercise intervention
studies in this particular patient group. People with dementia suffer
from complex problems and, thus, they may benefit from tailored ex-
ercise interventions targeted on their problems and needs. Many ex-
ercise interventions in this patient group are based on functional
exercises or exercises to improve executive functioning such as
dual-tasking. However, the intervention study to be included in this
review had to have exercise as the main component of intervention.
This physical exercise could include any type of physical activity
that was planned, structured, and repetitive for the purpose of condi-
tioning any part of the body. Physical exercise could be performed in-
dividually or in groups. It could include strength training, endurance
training, walking, balance training, dual-task training or training spe-
cific daily functions. The researchers selected the relevant studies
through discussion.
We divided the studies into two groups: 1. in people residing in
institutional care, and 2. in community-dwelling people.
We evaluated the methodological quality of the studies using a
modified rating system. In this rating system, we used criteria for
randomised intervention trials developed by the Cochrane library
which have been modified by Cochrane collaborators (Forbes et al.,
2008; Liu and Latham, 2009), as well as the PEDro scale, which is a
tool for measuring the methodological quality of clinical trials related
to physiotherapy practice (Maher et al., 2003) and criteria developed
by the Evidence-based Medicine Working Group (Guyatt et al., 1993,
1994). We added one more criterion to these because compliance is
often a problem in physical activity and exercise studies, and may di-
lute the effects of good interventions. The criteria are described in
Table 1. Each criterion was worth one point. If the study only partly
fulfilled the criterion, it received no point for that particular criterion.
The quality of the research was considered high, if the study earned
more than 10 points out of 13. Points from 7 to10 indicate moderately
high quality, and points below 7, poor quality. The researchers (KP,
MR, MLL, NS) evaluated the studies independently using the quality
criteria and discussed differences of opinions in order to reach
consensus.
We graded the evidence of efficacy based on the GRADE Working
Group (Atkins et al., 2004).The grading is based on design and quality
of reviewed studies, the consistency and direction of their findings
and other modifying factors such as sparse data, strong or very strong
association, risk of bias, evidence of a dose–response gradient and ef-
fect of plausible residual-confounding. We graded evidence on two
important outcomes: mobility limitations/functional limitations and
physical functioning. We also considered balance between benefits
and harms because exercise may have adverse effects such as falls.
 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93
Table 1
Criteria to evaluate the methodological quality of included studies. The criteria were
drawn from several sources (Forbes et al., 2008; Guyatt et al., 1993, 1994; Liu and
Latham, 2009; Maher et al., 2003). Each criterion is worth one point. Studies receiving
11–13 points are considered to be of high quality, those with 7–10 points of moderate
quality, and those below 7 points as poor quality.
1. The randomisation method is described adequately and acceptably
(a computerised randomisation program, a separate randomisation centre that
has no data on the participants)
2. The study population (diagnosis of dementia) is sufficiently well defined
(e.g. fulfils DSM-IV criteria or NINCDS-ADRDA criteria or a geriatrician or
neurologist made the diagnosis using adequate tests and MRI scans of the brain.
A diagnosis retrieved from medical records or an MMSE score alone was not
considered a valid definition).
3. Inclusion and exclusion criteria are accurately described.
4. The study has sufficient statistical power to detect differences between
changes in the groups. A justified power calculation in the article or – often
because of limited space in journal – the number of participants seems to
be adequate.
5. Measurements and outcome measures are clearly defined and valid.
6. Groups are comparable at baseline or outcome measures are adjusted as needed.
7. Drop-outs are described (e.g. flow chart, reasons for drop-outs and in which
phase of the study), and the analyses take them into account.
8. Analyses are performed on an intention-to-treat basis.
9. A comparison is made in relation to changes in outcome variables between
the groups.
10. A group assignment is blinded when assessing the outcomes.
11. The intervention is described in sufficient detail to be repeated.
12. The compliance of participants is described.
13. Complications are reported.
Evidence was graded as high if further research was considered un-
likely to change confidence in the estimate of effect; moderate if fur-
ther research was considered likely to have an important impact on
confidence in the estimate of effect and may change the estimate;
low if further research was considered very likely to have an impor-
tant impact on confidence in the estimate of effect and likely to
change the estimate; and very low is any estimate of effect is very un-
certain (Atkins et al., 2004).
3. Results
We found 20 randomised, controlled trials examining the efficacy
of exercise on dementia patients’ mobility, functional limitations or
physical functioning. A variety of types of exercises served to test
the efficacy of physical exercise (Tables 2 and 3). These varieties in-
cluded endurance training (e.g. walking, exercise bike, restorator
training) and strength training, balance/coordination training, or
functional exercises. The exercises were performed both in groups
and individually, with or without a professional supervisor. They in-
cluded also dual-task training to improve executive functioning or
practicing specific functional skills needed in daily activities. Often
training programmes were multimodal. The trial interventions as
well as in the outcome measures were therefore quite heterogeneous.
Therefore, we could not perform a meta-analysis of the findings or
calculate effect sizes. Instead, we described consequently individual
studies, their methodological strengths and limitations, and evaluated
their implications and possible grade of evidence.
3.1. Physical exercise interventions targeting on older people with
dementia in institutional care
We found 10 randomised studies (total n =575 participants) exam-
ining the efficacy of physical exercise among older institutionalised
people with dementia (Table 2). According to our evaluation eight stud-
ies were of poor quality. Problems in methodology were related mainly
87
to small sample sizes that failed to allow enough power to detect differ-
ences between the intervention and control arms (Buettner, 2002;
Christofoletti et al., 2008; Cott et al., 2002; Francese et al., 1997;
Kemoun et al., 2010; Santana-Sosa et al., 2008; Tappen, 1994; Tappen
et al., 2000), poorly described randomisation methods (Buettner,
2002; Francese et al., 1997; Kemoun et al., 2010; Santana-Sosa et al.,
2008; Stevens and Killeen, 2006; Tappen, 1994; Tappen et al., 2000)
and problems in treating drop-outs in analyses (Buettner, 2002;
Christofoletti et al., 2008; Cott et al., 2002; Francese et al., 1997;
Kemoun et al., 2010; Santana-Sosa et al., 2008; Stevens and Killeen,
2006; Tappen, 1994; Tappen et al., 2000). In many studies, the interven-
tion and control patients were incomparable at baseline; these differ-
ences were not adjusted in the final analyses (Buettner, 2002;
Christofoletti et al., 2008; Francese et al., 1997; Kemoun et al., 2010;
Santana-Sosa et al., 2008; Tappen, 1994). However, we found two stud-
ies of high or moderately high methodological quality. (Table 4)
To date, the largest exercise intervention study on physical function-
ing among institutionalised older people with dementia has taken place
in France (Rolland et al., 2007). The study fulfilled all of our quality criteria
(Rolland et al., 2007) (Table 4). The number of participants, retrieved
from nursing homes, was high (N=134). The diagnosis of Alzheimer's
disease, performed by geriatricians using diagnostic criteria, was
well-defined and supported by the MMSE score (b 25). The patients'
mean MMSE score was below 10, suggesting that most of them had se-
vere dementia. The patients were randomised into a control group and
an intervention group, which performed supervised physical exercise
for two hours per week for one year. Thus, the intensity of the interven-
tion was high, and the duration long. Valid measurements served to
measure physical functioning (Katz ADL index), behavioural and psycho-
logical symptoms of dementia (Neuropsychiatric Inventory), and depres-
sion (Montgomerry-Asberg Depression Scale). Only one in five dropped
out during the intervention year. However, despite the low drop-out
rate, the participation rate in the exercise sessions was poor: the mean
number of participations in the sessions was 33 out of 88. The statistical
analyses used “intention-to-treat” — method including all participants
in their randomised groups, and researchers used LOCF (last-
observation-carried-forward) analysis. Although Katz's ADL index is fairly
insensitive for measuring change, the physical functioning of the inter-
vention groups decreased more slowly in 12 months than did that of
the control group. There were no differences between the groups with re-
spect to nutrition, BPSDs or depression. The study also reported about the
safety of the intervention: there were no differences between the groups
in relation to falls, fractures or deaths, but participants in the intervention
group were admitted to hospitals significantly more often than were con-
trols during the intervention year.
In a study by Tappen et al. (2000), 65 participants with Alzheimer's
disease were randomised into three arms. The aim of the active treatment
was to improve the participants' executive functioning and mobility by
performing dual-task training (walking and talking simultaneously).
One intervention group did only walking exercises, the second had only
conversations and the third group did both (dual-tasking). Individually
performed intervention was conducted three times a week for
16 weeks. Participants in the dual-tasking group, which combined walk-
ing and conversation, showed a slower decline in mobility than did the
other groups. Dementia patients in particular appear to benefit from
this kind of training in executive functioning training (Schwenk et al.,
2010). However, this is the only study to explore the effects of dual-
tasking and comparing that with pure exercising and with pure conversa-
tion. One may question why the pure walking group did not benefit more
compared to pure conversation group. There are probably several reasons
behind this finding. First, the number of participants was small and, thus,
the study was underpowered to detect differences between walking and
conversation. Second, the pure walking (30 min self-paced walking with
resting in between) may have been too weak intervention to allow im-
provements. Third, the pure conversation group may have also benefitted
from cognitive stimulation in respect to executive functioning.
88 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93

Table 2
Randomized, controlled trials examining efficacy of physical exercise among institutionalised older people with dementia.

Study N, Study population Exercise type, time, frequency Intervention Effects on mobility(M) or Other effects Metodological
mean and duration performed in functional limitations (FL)/ quality
age, groups(G)/ physical functioning (PF) (points 0–13)
women individually
(%) (I)

Buettner, N = 24 NH-patients Walking, strength-, balance-, G Improvement in M (strength and Less falls Poor
2002 83 y MMSE b24, functional training walking distance) 2/13
NR mean 3 1×/day – duration?
Cott et al., N = 49 Insitutionalised 1) Dual tasking I No differences between the groups Poor
2002 82 y patients with 2) Conversation (as pairs) in M (ambulation) or PF 6/13
53% dementia 3) Control
MMSE b 20, mean 30 min × 5/week, 16 weeks
6
Christofoletti N = 54 Insitutionalised 1)Physiotherapy and I Improvement in FL (balance) in Improvement in Poor
et al., 2008 74 y patients occupational intervention groups compared with cognition in group 1 5/13
69% with dementia therapy 2 h × 5/week; 2) controls
(mixed type); Physiotherapy; 1 h× 3/week
mean MMSE 3) Control; 6 months
13-19
Francese et N = 12 NH-patients Various physical exercise, G Improvement in FL (muscle strength), Poor
al., 1997 NR AD-diagnosis music no differences in PF 3/13
20min × 3/week, 7 weeks
Kemoun et N = 38 NH-patients Walking, exercise bike, dancing ? Improvement in M (walking speed, Improvement Poor
al., 2010 82 y AD-diagnosis 1 h × 3/week, 15 weeks stride length) in cognition 6/13
74% MMSE b 23
Rolland et al., N = NH-patients Walking, strength, balance G Slower decline in PF (measured No differences in High
2007 134 AD-diagnosis 1 h × 2/week, 12 months by Katz ADL-index) BPSDs, depression 13/13
83 y mean MMSE 8 or nutrition
75%
Santana-Sosa N = 16 NH-patients Group exercise G Improvement in M and FL (muscle Poor
et al., 2008 73– AD-diagnosis; 75 min × 3/week, 12 weeks strength, flexibility, gait, balance) 6/13
76 y mean MMSE 20 and PF (Katz, Barthel)
63%
Stevens and N = NH-patients 1) Strength training of major G Improvement in PF in strength Improvement Poor
Killeen, 120 MMSE b24 muscles training group in cognition 3/13
2006 81 y 2) Social activity group in G1
75% 3) Control
30 min × 3/week, 3 months
Tappen, N = 63 NH-patients 1) Practice of ADL skills G Slower decline in PF in group Poor
1994 84 y dementia 2) Games and stimulation practicing ADL skills 3/13
65% diagnosis 3) Control
mean MMSE 6 2.5 h × 5/week, 20 weeks
Tappen et al., N = 65 NH-patients, 1) Walking I Slower decline in M (6-min Moderate
2000 87 y AD-diagnosis 2) Conversation walking test) in group practicing 8/13
84% mean MMSE 11 3) Dual-tasking (both) dual-tasking
30 min × 3/week, 16 weeks

AD = Alzheimer's disease; MMSE = mini mental state examination — cognition test (max 30); NR = not reported; NH = nursing home; y= year, min = minutes, h = hour; ADL =
activities of daily living; RCT = randomized controlled trial, BPSD = behavioral and psychological symptoms of dementia; G = group.

3.1.1. Physical exercise interventions targeted on home-dwelling older
people with dementia
We found 10 randomised studies (total n = 803 participants) that
investigated the efficacy of exercise on community-dwelling older
people with dementia (Table 3). Six studies had very small sample
sizes (Burgener et al., 2008; Kwak et al., 2008; Netz et al., 2007;
Schwenk et al., 2010; Steinberg et al., 2009; Toulotte et al., 2003), of
which two had negative results (Burgener et al., 2008; Netz et al.,
2007). Two of the ten studies were of high quality. They had a large
number of participants, and used valid measurements and analyses
(Schwenk et al., 2010; Teri et al., 2003). Both of these studies found
that intervention had positive effects on functional limitations. Five
studies were of moderately high quality (Miu et al., 2008; Pomeroy
et al., 1999; Shaw et al., 2003; Steinberg et al., 2009; Toulotte et al.,
2003): four of these showed improvements in functional limitations
in favour of the intervention group (Miu et al., 2008; Shaw et al.,
2003; Steinberg et al., 2009, Toulotte et al., 2003) but one found no
differences between the study groups (Pomeroy et al., 1999).
A high-quality American study examined whether guidance to in-
crease home-based physical activity and caregiver education was effec-
tive in home-dwelling Alzheimer's patients (Teri et al., 2003). The
number of participants was large (N= 153), their mean age was 78,
and their mean MMSE scores were 17. The study showed that interven-
tion decreased patients' symptoms of depression (Cornell depression
scale) and improved their physical role function measured with the
SF-36, which reflects functional deficits in older people (Syddall et al.,
2009). In line with many other studies targeting on dementia patients,
the proportion of drop-outs was quite high (22%). The intervention
was multidimensional and, in addition to physical exercise, also includ-
ed caregiver guidance. Therefore, whether the physical activity of the
patients or caregiver guidance improved their functional limitations re-
mains unclear. Although the methodological quality was high, the study
failed to describe in detail the home-based physical activity programme
and provided neither a description of their complications nor their com-
pliance with physical activity.
A high-quality German study (Schwenk et al., 2010) tested the effi-
cacy of strength-, balance- and dual-task training on people with mild
dementia. The participants were recruited from patients admitted to
hospital. The number of participants was moderately large (N= 61),
but after randomisation, ten participants opted out of the trial and
two additional participants dropped out. The final analyses did not
take these patients into account. The participants' mean age was 82,
 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93 89

Table 3
Randomized, controlled trials examining physical exercise intervention among community-dwelling older people with dementia.

Study N, Study population Exercise type, time, Intervention Effects on mobility(M) or Other effects Metodological
mean age, frequency performed in functional limitations quality
women (%) and duration groups(G)/ (FL)/ physical functioning (points 0–13)
individually (PF)
(I)

Burgener N= 43 Dementia, CDR b 2, Tai-chi exercises, G No differences between Improvement in Poor

et al., 77 y mean MMSE 24 cognitive-behavioral thera- intervention vs control in self-esteem 4/13
2008 47% pies M (strength, balance)
1 h× 3/week, 40 weeks
Kwak N= 30; NR; Dementia Various exercises ? Improvement in PF Improvement in Poor
et al., 100% mean MMSE 15 (e.g. restorator , staircase and (own measure) cognition 2/13
2008 shoulder wheel training)
30-60 min × 2-3/week,
12 weeks
Miu N= 85; Dementia patients Bicycle and hand – G Improvement in M No difference in Moderate
et al., 76 y; 74% from memory ergometer, (walking speed), not in PF cognition 7/13
2008 clinic 45-60min × 2/week, 3mo
Netz N= 29 Day center patients Group exercise (group G No differences between Poor
et al., 77 y with dementia, size13-15) intervention vs control in 6/13
2007 52% mean MMSE 13 2/week, 12 weeks M (strength, balance)
Pomeroy N= 81 Dementia patients Various types of exercise I No differences between No difference in nursing Moderate
et al., 82 y in respite care training with physiotherapist the groups in M (walking time spent on patients in 9/13
1999 74% 30 min × 5/week, 2 weeks ability) intervention and control
groups
Schwenk N= 61 Geriatric hospital Strength, balance and G Improvement in FL High
et al., 82y patients dual-task training (dual-task performance) 11/13
2010 64% MMSE b 26 2 h× 2/week, 12 weeks
Shaw N= 274 Emergency Physiotherapy at home/ I Improvement in M No decrease in number Moderate
et al., 84 y department care facility: walking, (gait performance) of falls 10/13
2003 80% patients after a fall, balance, strength
MMSE b 24 training, optimization of
mean 13 medication
frequency?, 3 months
Steinberg N= 27 AD/mixed Aerobic, strength and balance I Improvement in FL Moderate
et al., 75 y dementia training (hand functions); 10/13
2009 70% MMSE > 10 7x/week, 12 weeks no difference in PF
Teri N= 153 Home-dwelling, Physical exercise and I Improvement in FL Improvement in High
et al., 78 y AD caregiver education (physical role depression 11/13
2003 41% mean MMSE 17 30 min × 2-4/week, function measured
3 months, 2y follow-up with RAND-36)
Toulotte N= 20 Dementia patients with a Strength and balance training G Improvement in M Moderate
et al., 81 y; NR history of fall; MMSE b 21 45 min × 2/week, 16 weeks (walking speed 7/13
2003 and balance)

AD = Alzheimer's disease; y = year, NR = not reported; CDR = Clinical Dementia Rating; MMSE=mini mental state examination; min = minutes; h= hour.

and their mean MMSE score (21) was fairly high. Randomisation was
performed properly. Compared with the control group, the intervention
group's performance in dual-tasking improved.
One UK study (Shaw et al., 2003) was designed primarily to decrease
falls in older people with cognitive decline. In addition to home-based
physical exercise for three months, intervention included treatment of
diseases, optimisation of medications, and assessment of risk factors
for falls. The participants (N= 274) were older people with MMSE
scores b24, a history of falling and who had been admitted to the emer-
gency department due to a fall. Mean age 84 years was high. Although
the diagnosis of dementia was not defined with specific criteria, most
of the patients apparently had dementia as the mean MMSE score was
13. Performance in walking improved significantly in the intervention
group. However, no differences were found in major outcome mea-
sures: falls and fractures. About two thirds of participants complied
with gait and balance training.
Pomeroy et al. (1999) examined whether physiotherapeutic treat-
ment with various exercises given for two weeks every workday dur-
ing a two-week period of respite care can enhance mobility in
dementia patients. The control group participated in other activities.
The participants' mean age 82 years was high. A psychiatrist carefully
determined dementia diagnoses. The study was carefully blinded: re-
searchers used video-recording and two independent evaluators to
assess outcomes. Although nine participants dropped out during the
study, the researchers used “intention-to-treat” analysis. Intervention
did not lead to improvements in mobility, possibly due to the short
duration of the intervention.
Steinberg et al. (2009) investigated the efficacy of exercise train-
ing in dementia patients with Alzheimer or mixed type. The training
programme was intensive and included brisk walking as well as
strength and balance training seven times a week for 12 weeks. The
participants and their relatives were responsible for executing the
training programme. Of the intervention group, 59% returned their
training diary and 72–79% of them reported exercising according to
the objectives of the training programme. The researchers reported
results from 13 measurements (e.g. NPI, Cornell, quality of life, care-
giver burden), of which only one showed improvement in favour of
the intervention group. Intervention improved hand functions indi-
cating improvement in functional limitation. However, they found
no differences in mobility between the groups, and there was more
depression and lower quality of life in the intervention group. The
number of participants was small (N = 27) and the researchers used
no power calculations.
The study of Toulotte et al. (2003) used a very small number of
participants (N = 20). Strength, balance and stretching training
were scheduled for two hours a week for a 16-week period. Walking
speed and balance in the intervention group improved, but re-
searchers did not report the differences between the groups, but
within the groups at different time points. The study was blinded,
and intervention, compliance and complications were rather well
 90
Table 4
Evaluation of the quality criteria fulfillment in randomized controlled trials examining physical exercise interventions among people with dementia.

Study Randomization Valid Inclusion Adequate Valid Baseline Drop-outs Intetion- Comparison Blinding Description Compliance Complications
described and definition and statistical measurements characteristics in described to-treat of differences used of described described
acceptable of exclusion power or and outcome groups and analysis in changes interven-tion
dementia criteria justified with measures described + groups included between
described power comparable in analyses the groups in
calculation outcome

K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93

variables

Studies performed among institutionalised older people with dementia

Buettner, 2002
Cott et al., 2002
Christofoletti et al., 2008
Francese et al., 1997
Kemoun et al., 2010
Rolland et al., 2007
Santana−Sosa et al., 2008
Stevens and Killeen, 2006
Tappen, 1994
Tappen et al., 2000
− − + − − − ? ? − − + − −
+ − + − + + +/− − − + + − −
+ +/− + − + − − − + − + − −
− + − − + − − − + − − − −
− + + − + − − − + − + + −
+ + + + + + + + + + + + +
− + + − + − − − + − + + +/−
− ? ? + + − − − − ? + − −
− +/− + − + − − − − − + +/− −
− + + − + + − − + + + + −

Studies made among community-dwelling older people with dementia

Burgener et al., 2008 − +/− − − + + − − + − + +/− −
Kwak et al., 2008 − +/− + − − − ? ? − − + ? −
Miu et al., 2008 − + + + + +/− +/− − + + + − −
Netz et al., 2007 − − + − + + + − + − + ? −
Pomeroy et al., 1999 − + + + + +/− + − + + + + −
Schwenk et al., 2010 + + + − + + + − + + + + +
Shaw et al., 2003 + − + + + + + + + − − + +
Steinberg et al., 2009 − + + − + + − + + + + + +
Teri et al., 2003 + + + + + + + + + + +/− +/− +
Toulotte et al., 2003 − ? + − + − +/− ? + + + + +

+ = fulfills criteria; − = does not fulfill criteria; +/− = fulfills criteria only partly; ? = cannot be concluded from the study report.
 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93
reported. However, its methodology has a number of problems: the
dementia of the participants was poorly defined, baseline characteris-
tics were not described and remains unclear whether they used the
intention-to-treat analysis.
Other physical exercise intervention studies of home-dwelling
older people with dementia were of poor quality (Burgener et al.,
2008; Kwak et al., 2008; Netz et al., 2007). None of these studies de-
scribed their randomisation method, all had a small number of partic-
ipants and one study (Burgener et al., 2008) failed to provide the
number of drop-outs or the use on intention-to-treat analysis. This
makes evaluation of the study's statistical power difficult. Only the
Korean study (Kwak et al., 2008) showed the efficacy of physical ex-
ercise on physical functioning. However, the measurement was not
validated, and the evaluation of efficacy was not based on differences
between the groups (Kwak et al., 2008). The other two studies failed
to show efficacy at all (Burgener et al., 2008; Netz et al., 2007).
4. Discussion
We found 20 randomised, controlled trials that examined the effi-
cacy of physical exercise on dementia patients’ mobility/functional
limitations or physical functioning or both. Nine studies were consid-
ered to be of high or moderately high methodological quality. Six of
these studies demonstrated positive effects on mobility or functional
limitations, and an additional two even on physical functioning. Only
one study of moderate methodological quality found no efficacy prob-
ably due to short duration of exercise. Compared to other older
populations, physical exercise interventions have relatively rarely
targeted older people with dementia. However, the topic has recently
gained more attention. The past three years have seen seven physical
exercise intervention studies published, and several others are ongo-
ing (e.g. Cerga-Pashoja et al., 2010; Hill et al., 2009; Pitkala et al.,
2010).
Patients with dementia are at high risk for falls, suffer from mobil-
ity limitations in early stages of their disease, and experience severe
disabilities in moderate and severe stages of the disease. Despite the
magnitude of the problems related to their functional limitations
and disability as well as the risk for fractures, surprisingly few
high-quality studies have investigated the effectiveness of exercise
or rehabilitation among patients with dementia. In most Western
countries, this patient group is the largest patient group in need of
home care and institutional care; dementia is therefore one of the
most expensive diseases to manage (Gustavsson et al., 2011).
Sixteen of our reviewed studies showed efficacy either on func-
tional limitations or on physical functioning. Those four not showing
any efficacy had obvious reasons for their negative findings: three of
them were of poor quality and had small sample sizes not allowing
enough statistical power to show differences between the groups
(Burgener et al., 2008; Cott et al., 2002; Netz et al., 2007) whereas
in one study the duration of intervention was only two weeks
(Pomeroy et al., 1999). The only high-quality study showing efficacy
on physical functioning had a very long-term intervention, lasting
for 12 months (Rolland et al., 2007).
Most of the reviewed studies assessed had methodological prob-
lems. Fewer than half adequately described the randomisation meth-
od, and the size of the intervention and control groups was often
unequal. The question of whether randomisation was performed
properly, therefore remains in doubt. Several studies had a small
number of patients and, consequently low statistical power to show
differences between the groups. Several studies failed to accurately
define their patient group and thus leaving the diagnosis of dementia
obscure. In many studies, the definition of dementia relied only on
the MMSE score, which does not justify a diagnosis of dementia. In
many studies, the description of the baseline characteristics was
vague, absent, or the groups differed significantly from each other
with respect to certain characteristics that may affect outcomes. A
91
blind study design is difficult to arrange adequately in such clinical
studies, but in nine studies, the researchers did attempt to do so.
Most of the studies usually validated and justified their measure-
ments and outcomes well, and also described the intervention well.
It is worth noting that altogether eight of the nine high or moder-
ately high quality studies (Miu et al., 2008; Rolland et al., 2007;
Schwenk et al., 2010; Shaw et al., 2003; Steinberg et al., 2009;
Tappen et al., 2000; Teri et al., 2003; Toulotte et al., 2003) found
that physical exercise improves the mobility, functional limitations
or physical functioning of older people with dementia. One study
had a clear reason for its modest results: a short intervention period
of only two weeks (Pomeroy et al., 1999). Determining the real effect
sizes and performing a meta-analysis was, however, impossible. The
studies share a high degree of heterogeneity in intensity, duration
and type of exercise performed. In addition, the outcome measures
vary considerably and are not comparable with each other. The target
groups also differ from one study to another: patients in mild stages
of dementia differ substantially from those in more severe stages
and may not benefit from same types of exercises.
Two of the studies reporting positive effects used a multicomponent
intervention (Shaw et al., 2003; Teri et al., 2003), which makes it diffi-
cult to determine the specific effect of the physical exercise. The same
problem with multimodal interventional components concerns dual-
tasking which was especially explored in Tappen's (2000) study:
dual-tasking was beneficial but walking alone not. In other studies,
three used strength and balance training (Rolland et al., 2007;
Schwenk et al., 2010; Toulotte et al., 2003), two dual-tasking
(Schwenk et al., 2010; Tappen et al., 2000), and one an aerobic cycle-
ergometer (Miu et al., 2008). In fact, most of the effective, high quality
studies used multimodal interventions by combining various types of
exercises (Rolland et al., 2007; Schwenk et al., 2010; Shaw et al.,
2003; Steinberg et al., 2009; Toulotte et al., 2003), using dual-tasking
in exercises (Schwenk et al., 2010; Tappen et al., 2000) or combining ex-
ercises to other interventional components (Shaw et al., 2003; Teri et
al., 2003). In studies with a positive outcome, the frequency of interven-
tion was at least twice per week and usually with a progressive increase
in intensity (Rolland et al. 2007; Schwenk et al., 2010; Tappen et al.,
2000). The duration of the intervention varied from 12 weeks
(Schwenk et al., 2010) to 16 weeks (Tappen et al., 2000; Toulotte et
al., 2003), and even up to one year (Rolland et al., 2007). Effective inter-
ventions relied on both individual- (Shaw et al., 2003; Tappen et al.,
2000; Teri et al., 2003) and group-based exercises (Rolland et al.,
2007; Schwenk et al., 2010; Toulotte et al., 2003).
That the older studies were implemented in institutional settings is
understandable (Table 2), because the studies executed in institutional
settings cost less, and participant compliance is easier to confirm.
However, many of these earlier studies suffer from methodological
limitations. Although the studies had few participants and weak power,
their findings show positive trends. The frailty of institutional patients
or a decline in their cognitive functioning does not seem to decrease the
effectiveness of the rehabilitation. However, a publication bias favouring
positive study results may be present. In addition, generalising these find-
ings to home-dwelling older people with dementia is problematic.
Only a few studies have reported participant compliance or com-
plications (e.g. falls, fractures or hospitalisations), and compliance be-
tween them varies. In long-term studies and those with intensive
intervention, compliance has been low. Patients with Alzheimer's dis-
ease participated in a mean of 33 of 88 sessions, although only a fifth
completely dropped out during the year-long intervention period
(Rolland et al., 2007). In another study, about two in three interven-
tion group participants committed to walking and balance training
(Shaw et al., 2003). In the study by Tappen et al. (2000), 75% partici-
pated in dual-tasking groups, and in a German study, the compliance
rate was 92% (Schwenk et al., 2010). In studies reporting complica-
tions, groups showed no difference from each other with respect to
falls or fractures (Rolland et al., 2007). In one study (Shaw et al.,
92 K. Pitkälä et al. / Experimental Gerontology 48 (2013) 85–93
2003), such complications neither increased nor decreased, whereas
in another, no one in the intervention group and six in the control
group fell (Toulotte et al., 2003). One study showed increase in hospi-
talizations (Rolland et al., 2007). However, there is scarce of trials
reporting harms of exercise. Therefore, there is uncertainty whether
benefits of exercise overcome its possible harms.
Researchers often include in their analyses only those who com-
plete the study, which may overestimate efficacy. Understandably,
studies about older people with dementia have a significant propor-
tion of drop-outs due to complications, hospital admissions, and
deaths, which are common in such frail populations. On the other
hand, this high number of endpoints may also be a strength of the
study. In physical exercise interventions, it is imperative that profes-
sionals tailor interventions in a patient-centred way in order to main-
tain high compliance. Doing so, however, may pose a challenge due to
heterogeneity in the cognitive and functional status of the study
populations.
In summary, we can conclude there is moderate grade of evidence
that intense exercise (at least twice per week) for at least three
months entailing several types of exercises may improve at least
some dimensions of mobility or functional limitations among patients
with dementia. Further research will confirm whether benefits are
greater than the harms. However, only low grade of evidence sug-
gests that intense and long-duration exercise training can improve
the physical functioning of patients with dementia. There is still
only one high-quality randomized trial showing efficacy of exercise
on physical functioning of patients with dementia.
5. Conclusions
Although 20 randomised studies aimed to clarify the effects of ex-
ercise on dementia patients’ mobility and physical functioning, only a
few of them are of high quality. The high-quality studies nevertheless
demonstrate fairly consistently that intensive physical exercise may
improve the mobility or functional limitations of older people with
dementia (Miu et al., 2008; Schwenk et al., 2010; Shaw et al., 2003;
Steinberg et al., 2009; Tappen et al., 2000; Teri et al., 2003; Toulotte
et al., 2003). In addition, both intensive and long-term physical exer-
cise intervention may improve physical functioning as well (Rolland
et al., 2007).
Acknowledgements
This study was supported by the Social Insurance Institution of
Finland, the Central Union for the Welfare of the Aged, the Sohlberg
Foundation, and the King Gustaf V and Queen Victoria's Foundation.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://
dx.doi.org/10.1016/j.exger.2012.08.008.
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